Project Name: ___________________________________________
Location/Area: __________________________________________
Date: [//_____]
Name of Reporter: _______________________________________
Role/Position: __________________________________________
Contact Information: _____________________________________
Time of Observation: _____________________________________
Specific Location of Hazard: ______________________________
Type of Hazard: (e.g., Slip and Trip, Electrical, Chemical, Mechanical, etc.)
Description of the Hazard:
Immediate Actions Taken (if any):